by Christina Pazzanese, Harvard Gazette

Chika Anekwe, obesity medicine physician at the Mass General Weight Center. Credit: Stephanie Mitchell/Harvard Staff Photographer

The frenzy of demand for new, FDA-approved drugs like Ozempic, used to treat diabetes, has been fueled in part by reports that celebrities like Oprah Winfrey, Elon Musk, and various social media influencers have lost significant amounts of weight in relatively short time. But it also hit a cultural nerve.

The need for more effective weight-loss treatments is clear. Nearly 42% of American adults are obese, a condition that disproportionately affects older adults and racial/ethnic minorities, according to the CDC's National Health and Nutrition Examination survey. And about 80% of people who lose weight gain most of it back within two years, research shows.

But the sudden popularity of these medications has been accompanied by news and opinion pieces and social media criticism questioning the safety, efficacy, and cost of the treatments. It has also triggered a backlash against users. Called "Ozempic shaming," many users face stigma and negative comments online and in person for taking these medications instead of relying on diet and exercise.

Chika Anekwe is an obesity medicine physician at the Mass General Weight Center and an instructor at Harvard Medical School. Anekwe spoke with the Gazette about the drugs, the complexities of treating obesity, and the social stigma against being overweight. This interview has been edited for clarity and length.

Why has there been so much backlash to these medications, especially from people who've never used them or who have no obesity medicine expertise?

Fear and bias are the main causes for backlash. Mistrust of the medical community is another potential explanation for the vigor with which people are so opposed to the use of medications for weight management.

Also, the belief that has been so ingrained in our minds is that you should be able to maintain a healthy weight by yourself and anything you're using, other than a healthy diet and exercise, to help is considered cheating or evidence of a lack of willpower. People think that they can will themselves out of this disease, whereas you wouldn't ever say to someone with cancer or any other chronic illness, "Don't take medicine. You can cure yourself if you simply try hard enough." That's not how it works.

Because many don't think of chronic excess weight as a disease?

That's definitely part of it. They think metabolic disease is the real disease, and obesity is just a symptom of it. So, if we treat the metabolic disease then I guess they think the obesity will go away.

All the things we recommend for treating metabolic disease are the same things we recommend for treating obesity. That's literally what we're doing when we treat obesity. But I guess we should do it without the medications—that's their perspective.

Because of the pharmaceutical industry's influence, many people assume physicians are agents of Big Pharma and the health care–industrial complex. There's an assumption that physicians are paid to prescribe medications because it's in our own interest to do so where in truth, we are paid to care for sick people.

The challenge is that lifestyle, behavioral, and preventive measures can only go so far, so in our current modern lifestyle, pharmacotherapy and even bariatric surgery are necessary tools in the obesity treatment armamentarium.

Many are hearing about these drugs because of celebrities, not from a medical journal. Could that help explain the perception that these are just an expensive, vanity-driven quick fix?

I don't doubt that. The fact that people are hearing about Ozempic from TikTok or a random blog because Oprah Winfrey or Kim Kardashian or whoever else are using it versus "I opened up the New England Journal of Medicine and saw the five-year Cardiovascular Outcomes Study, and now I think I can talk to my doctor about this" is very indicative of the problem. People need to be aware of the sources of their information and be critical in evaluating the credibility of those sources.

Being overweight carries greater risk for heart disease, diabetes, and some cancers. But research also shows the stigma of being overweight has been linked to medical-care avoidance, less-diligent treatment from clinicians, and many social, financial, and educational difficulties. Is it possible such bias may pose greater health risks than being overweight in some cases?

When people are looking down on or judging somebody for their excess weight, that's weight stigma. Self-stigma is when those perceptions are internalized. The person starts to believe they have these negative characteristics associated with having excess weight.

A study by April Prunty and colleagues looked at those two types of stigma, as well as outcomes related to physical health, health care utilization, and selected health behaviors including physical activity and smoking. It showed that people who experienced both weight stigma and self-stigma had worse physical and mental health outcomes. They had less health care utilization (i.e., were more likely to avoid or delay medical care) and were more likely to lead sedentary lifestyles.

So, all the negative attitudes and beliefs about people with excess body weight become internalized and lead to worse health outcomes, further compounding the health problems. It goes beyond poor self-image. It's all these downstream effects of wanting to avoid health care access and taking less care of yourself because you believe all these negative attitudes and beliefs about yourself.

Why are weight bias and stigma so prevalent?

It's that concept of behavior and lifestyle being a component of treatment and people thinking that it should be the whole treatment. And the notion that willpower is the main cause of obesity as opposed to there being physical, environmental, genetic, and other factors that contribute to it.

Also, a lack of knowledge of some of the socioeconomic factors that play into it. Somebody who has easy access to healthy foods and doesn't have to think twice about where they shop or being able to afford groceries, might not recognize how difficult it might be for somebody living in a rural area or in a low-income area or being a single parent and having different economic and logistical factors working against them toward being healthy.

Many people have some baseline knowledge of the components that lead to obesity, but they're not recognizing how there isn't just one solution to the problem.

Have the medical and public health communities done enough to educate the public about all the factors that go into weight management and that some people do need surgical or medicinal interventions?

With the exception of cosmetic procedures, there's no other medical condition subject to the uninformed and often judgmental opinions of the general public. So, we could probably do better.

All the research and clinical trials published are the [same] facts we tend to share with people, whether it's through one-on-one encounters with patients or online media, articles, interviews. So, the information is getting out there, but it's just not getting taken up by the public, likely because it's getting drowned out by the flashier, more palatable content put out by social media influencers.

There's also more that should be and, I would hope, is being done at the primary care level. The question is: Do people have reliable access to primary care? Not everybody does, and certainly not at the rate at which it is needed due to the primary care shortage we are currently experiencing in health care. People oftentimes go years without seeing a PCP if they consider themselves to be otherwise healthy.

What should the public keep in mind when it comes to weight loss?

The main thing people should be aware of is that we shouldn't be looking at or talking about BMI anymore at all when it comes to an individual's health. It is something that we use when we talk to the insurance companies, because that's how they still process approvals. But BMI has so many issues based on how it was developed, the way it was originally intended to be used, that don't apply to treating an individual patient in the clinical setting. So, understanding that is key.

Also, understanding that excess body weight isn't a person's fault. It is a disease, and it has consequences. Having excess weight doesn't automatically mean you are unhealthy, but it does raise your risk for disease, both presently and in the future. Another point: Excess body fat is the concern, not excess weight overall. If you're heavy because you're a bodybuilder who has high muscle mass, that's not a health risk. So, these different concepts are key to understand.

I would also emphasize to people, if they have concerns about their weight or their health, that the first person they should be speaking to is their primary care doctor. If they want to then proceed with a referral to a weight specialist, we are here. Many of us are responsible in how we treat and prescribe these medications and would be happy to help anybody who has concerns and wants to discuss their health.

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